CASE INFORMATION

Case ID: CCE-CE-010
Case Name: Sarah Thompson
Age: 38
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: X02 (Menstrual Problems), W78 (Obesity), L92 (Iron Deficiency Anaemia), P76 (Depressive Disorder)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations 1.2 Uses active listening and empathy to explore the patient’s illness experience 1.5 Provides clear and sensitive explanations of potential diagnoses and management options
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history to assess the cause of menstrual and general health concerns 2.2 Identifies red flags for underlying gynaecological or systemic conditions 2.3 Orders and interprets appropriate investigations to confirm diagnosis and assess risk factors
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises clinical features suggestive of common women’s health conditions (e.g., menorrhagia, anaemia, polycystic ovary syndrome) 3.3 Considers and rules out alternative diagnoses, including malignancy
4. Clinical Management and Therapeutic Reasoning	4.2 Provides appropriate counselling, lifestyle advice, and treatment options 4.4 Arranges specialist referral if indicated (e.g., gynaecology, haematology, psychology)
5. Preventive and Population Health	5.2 Provides education on lifestyle modifications, contraception options, and long-term risk reduction strategies
6. Professionalism	6.2 Demonstrates sensitivity in discussing personal and potentially stigmatising health concerns
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate screening and follow-up for women’s health issues, including cervical screening and preconception planning
9. Managing Uncertainty	9.1 Addresses patient concerns about long-term health implications and psychological impact
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and initiates management for significant menstrual disorders, anaemia, and mental health concerns

CASE FEATURES

Anxious about potential underlying causes, including endometrial cancer or hormonal imbalance.
38-year-old woman presenting with heavy and irregular periods, fatigue, and low mood.
Menorrhagia for over a year, worsening in the past six months.
Recent blood test showed iron deficiency anaemia.
Overweight (BMI 31), with concerns about weight gain and fertility.
Increased work stress and difficulty managing family responsibilities.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

Sarah Thompson, a 38-year-old teacher, presents to your general practice with heavy, irregular periods and increasing fatigue over the past year. She recently had a blood test that showed iron deficiency anaemia.

Sarah is concerned about her fertility, as she and her partner have been trying to conceive for a year without success. She is also worried that her symptoms could be a sign of something serious, like cancer or a hormonal imbalance.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 38
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

No known history of gynaecological conditions
No previous iron deficiency

Social History

Occupation: Teacher, reports high work stress
No smoking, drinks alcohol occasionally (2-3 drinks per week)

Family History

Mother had heavy periods but no known diagnosis
No known family history of endometrial or ovarian cancer

Vaccination and Preventative Activities

Cervical screening up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, my periods have been really heavy and irregular, and I’m feeling exhausted all the time. I’m worried something serious is going on.”

General Information

(Can be shared freely if asked open-ended questions like “Tell me more about that.”)

Your periods have been heavier and more irregular for about a year, but the last six months have been worse.
They last more than seven days, and sometimes you have flooding, clots, or need to change pads every hour.
Some months you skip a period, but when it comes, it’s extremely heavy.
You have been feeling constantly tired and weak, even after a full night’s sleep.

Specific Information

(Only Reveal When Asked Directly)

Background Information

You have been trying to conceive for a year, but nothing has happened yet.
You haven’t spoken to a doctor about fertility before, but you’re starting to get worried.
You have gained about 8 kg in the last two years, and you feel bloated and sluggish most days.
You have been more stressed than usual due to work and life responsibilities, and sometimes you feel overwhelmed.
You feel like your mood has been low, but you’re not sure if it’s because of the fatigue or stress.

Menstrual and Gynaecological Symptoms

You have no severe period pain, but sometimes feel pelvic discomfort when your period is heavy.
You have not noticed unusual vaginal discharge or bad odour.
You have never had abnormal Pap smear results.
Your mother also had heavy periods when she was younger, but she never had a formal diagnosis.

General Health and Lifestyle

Your diet is not great—you often skip breakfast and eat processed foods due to a busy schedule.
You rarely exercise, and feel too tired most of the time to do so.
You sometimes feel dizzy or lightheaded when you stand up quickly.
You don’t smoke and drink alcohol occasionally (2-3 drinks per week).

Fertility Concerns

You have never been pregnant before and never had a miscarriage.
You don’t track ovulation, but you and your husband have been having regular unprotected sex for a year.
You are worried that this means you won’t be able to get pregnant.

Mental and Emotional State

You feel frustrated and stressed about your symptoms, especially the exhaustion and weight gain.
You sometimes cry easily and feel like you’re not coping as well as you used to.
You worry that something serious is wrong, like cancer or early menopause.
You haven’t talked to your partner much about how you’re feeling because you don’t want to stress him out.

Concerns and Questions for the Candidate

(Ask these naturally during the consultation, especially when discussing diagnosis or management.)

“Why is this happening to me? Could it be cancer?”
“Is this a hormonal issue? Could I have a thyroid problem?”
“Will I be able to have a baby? Should I see a fertility specialist?”
“Is my weight making this worse? Does this mean I need to lose weight to get pregnant?”
“What can I do to feel better? Do I need iron supplements or something stronger?”
“Could this be early menopause? Am I running out of time to have kids?”
“Do I need surgery for this, or is there another way to treat it?”

Role-Playing Emotional Cues

(Act these out realistically to simulate a real patient encounter.)

Anxiety: Look tense and fidget when talking about fertility and the possibility of cancer.
Frustration: Cross arms or sigh when discussing fatigue and difficulty losing weight.
Embarrassment: Look down or avoid eye contact when talking about trying to conceive.
Tearfulness: Become slightly emotional when discussing stress or fear of infertility.
Relief (if reassured well): Sit up straighter, nod, and speak more calmly when the doctor explains things clearly.

What You Are Expecting From the Doctor (Candidate)

To take your concerns seriously. You don’t want to be brushed off or told that heavy periods are just normal.
To explain what’s happening. You want answers about why your periods are like this, what’s causing the fatigue, and whether this will affect your fertility.
To tell you what tests you need. You don’t just want to be given iron supplements—you want to know the cause of the problem.
To talk about fertility options. You need reassurance that this isn’t the end of the road for having a baby.
To discuss treatment options. You are open to medication but don’t want surgery unless necessary.
To give you hope. You want to feel like you have control over your health and that things can improve.

Potential Curveballs

(Optional, if the Candidate Handles the Basics Well)

“Would going on the Pill help, or would that make it worse?”
“My friend had fibroids—could I have that?”
“Should I be seeing a specialist instead of a GP for this?”
“Could this be diabetes? I heard it can cause tiredness and period problems.”
“Do I need an ultrasound or biopsy to check for anything serious?”

End of Consultation

(If the candidate provides a clear plan and reassurance, respond positively.)

“Okay, that makes sense. I just want to feel like myself again. I’ll do the tests and follow your advice.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, exploring the patient’s symptoms and risk factors.

The competent candidate should:

Use open-ended questions to explore menstrual irregularities, heaviness, and associated symptoms.
Clarify onset, duration, severity, and impact on daily life of heavy menstrual bleeding (HMB).
Assess for red flag symptoms, including:
- Postcoital bleeding, intermenstrual bleeding, or sudden cycle changes (suggesting malignancy).
- Severe pain, dyspareunia, or bloating (suggesting endometriosis, fibroids, or ovarian pathology).
- Rapid weight loss, night sweats (suggesting malignancy or systemic disease).
Explore fertility concerns, assessing timing of intercourse, past pregnancy history, ovulatory symptoms, and previous investigations.
Identify risk factors for hormonal imbalances, such as obesity, insulin resistance, thyroid dysfunction, or polycystic ovary syndrome (PCOS).
Assess impact on quality of life, including mood changes, stress levels, and relationship concerns.

Task 2: Outline your differential diagnosis, discussing the most likely causes and serious considerations.

The competent candidate should:

Consider dysfunctional uterine bleeding (anovulatory cycles) as a likely cause given:
- Irregular cycles with heavy bleeding.
- Obesity (linked to oestrogen excess and anovulation).
Discuss other possible diagnoses, including:
- Endometrial hyperplasia/cancer – especially given age >35, obesity, and prolonged anovulation.
- Fibroids (leiomyomas) – may present with heavy, prolonged bleeding and pelvic pressure.
- PCOS – commonly causes irregular periods, weight gain, and infertility.
- Thyroid dysfunction – can cause menstrual disturbances and fatigue.
- Coagulation disorders (e.g., von Willebrand disease) – consider if lifelong history of heavy bleeding.
Rule out pregnancy-related complications (e.g., early miscarriage, ectopic pregnancy).

Task 3: Address the patient’s concerns regarding her symptoms, fertility, and long-term health risks.

The competent candidate should:

Acknowledge the patient’s distress and anxiety, especially about fertility and cancer fears.
Provide reassurance that many causes of heavy periods are treatable and not all indicate malignancy.
Explain the link between obesity, anovulation, and heavy bleeding, reinforcing the role of weight management in symptom control and fertility.
Discuss the role of lifestyle changes, medical management, and potential need for specialist referral.
Address fertility concerns by explaining the role of ovulation tracking, weight loss, and medical interventions if needed.

Task 4: Provide a structured management plan, including investigations, treatment, and follow-up.

The competent candidate should:

Order appropriate investigations, including:
- Full blood count (FBC) and iron studies (assess anaemia).
- Thyroid function tests (rule out hypothyroidism).
- Serum prolactin and androgens (if suspecting PCOS).
- Pelvic ultrasound (assess endometrial thickness, fibroids, or ovarian pathology).
- Endometrial biopsy (if >35 years, obesity, prolonged anovulation).
Initiate medical management, including:
- Tranexamic acid or NSAIDs for short-term symptom relief.
- Combined oral contraceptive pill (COCP) or Mirena IUD for long-term cycle control.
- Metformin if PCOS with insulin resistance.
- Iron supplementation if anaemia is present.
Address lifestyle factors, advising:
- Weight loss strategies, dietary improvements, and regular exercise.
- Referral to a dietitian if needed.
Plan follow-up:
- Review in 4–6 weeks to assess response to treatment.
- Consider referral to gynaecology if symptoms persist or investigations suggest structural pathology.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, covering menstrual cycle changes, fertility concerns, and systemic symptoms.
Clear differential diagnosis, considering hormonal, structural, and malignancy-related causes.
Empathetic and structured reassurance, addressing concerns about cancer, infertility, and long-term health risks.
Evidence-based management plan, including investigations, hormonal therapy, lifestyle advice, and referral if needed.
Comprehensive follow-up plan, ensuring ongoing symptom management and patient-centred care.

PITFALLS

Failing to explore red flag symptoms, leading to missed diagnosis of endometrial hyperplasia/cancer.
Dismissing the patient’s fertility concerns, assuming she is not actively trying to conceive.
Over-reassurance without appropriate investigations, delaying diagnosis and treatment.
Not considering lifestyle modifications, missing an opportunity for long-term hormonal balance.
Failure to arrange follow-up, leading to poor symptom control and worsening anaemia.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.5 Provides clear and sensitive explanations of potential diagnoses and management options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history to assess the cause of menstrual and general health concerns.
2.2 Identifies red flags for underlying gynaecological or systemic conditions.
2.3 Orders and interprets appropriate investigations to confirm diagnosis and assess risk factors.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features suggestive of common women’s health conditions (e.g., menorrhagia, anaemia, polycystic ovary syndrome).
3.3 Considers and rules out alternative diagnoses, including malignancy.

4. Clinical Management and Therapeutic Reasoning

4.2 Provides appropriate counselling, lifestyle advice, and treatment options.
4.4 Arranges specialist referral if indicated (e.g., gynaecology, haematology, psychology).

5. Preventive and Population Health

5.2 Provides education on lifestyle modifications, contraception options, and long-term risk reduction strategies.

6. Professionalism

6.2 Demonstrates sensitivity in discussing personal and potentially stigmatising health concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate screening and follow-up for women’s health issues, including cervical screening and preconception planning.

9. Managing Uncertainty

9.1 Addresses patient concerns about long-term health implications and psychological impact.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and initiates management for significant menstrual disorders, anaemia, and mental health concerns.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD